MINI CAMP
2019 YMCA OF GREENWICH
SUMMER DAY CAMP
ENROLLMENT FORM
Child’s Name: Nickname: Gender: Date of Birth: Age: Grade in Sep, 2019: Languages Spoken @ Home: Home Address: City: Zip Code: Parent/Guardian Name(s): Primary Emergency Contact & Relation to Child: Home Address (if different from child): Cellphone: Would you like to be contacted via Text? If yes, please provide carrier: Work Telephone: Work Hours: Email: Employer/ Address: Current Greenwich YMCA Membership: Family Youth Non Member T-Shirt Size (One per camper given by end of first day of camp) S M L XL CAMP DETAILS Half Day Camp Full Day Camp
Monday - Friday Monday - Friday
SESSION DATES
HALF DAY Y MEM FEE
HALF DAY NON MEM FEE
June 24-28 *July 1-5 (no camp July 4) July 8-12 July 15-19 July 22-26 July 29-August 2 August 5-9 August 12-16 PAYMENT METHOD:
$250 *$200 $250 $250 $250 $250 $250 $250
$300 *$240 $300 $300 $300 $300 $300 $300
Check
Visa
8:30am - 1pm 8:30am - 5:30pm FULL DAY Y MEM FEE
$400 *$320 $400 $400 $400 $400 $400 $400 MC
FULL DAY NON MEM FEE
$460 *$368 $460 $460 $460 $460 $460 $460 AMEX
TOTAL
$ $ $ $ $ $ $ $ TOTAL $
CC Number: Expiration Date: CVV Number: I wish to enroll my child in the YMCA of Greenwich Summer Camp 2019. I understand and agree that my child will not be able to attend camp until all emergency information, medication authorization consent, current Health Forms, and parent consent agreements are completed and returned to the Y. Signature: Date: *ALL FEES DUE BY JUNE 1. NO REFUNDS WILL BE GRANTED AFTER JUNE 1 Please make checks payable to: YMCA of Greenwich, 50 East Putnam Ave, Greenwich, CT 06830
2019 YMCA OF GREENWICH
SUMMER DAY CAMP
EMERGENCY CONTACTS
CHILD’S NAME: TEAM NAME: OTHER PARENT/GUARDIAN INFORMATION Parent/Guardian Name: Relation to Child: Home Address: Cellphone: Work Telephone: Work Hours: Email: Employer/ Address: EMERGENCY CONTACTS / AUTHORIZED PICK-UP PERSONS
Please list, in order to be contacted, individuals we may contact in an emergency/non-emergency, if you cannot be reached. Persons listed as “Emergency Contacts” are authorized to pick up your child from the program. NOTE: Parents/Guardians may not be listed under this section. The YMCA of Greenwich requires at least 3 emergency contacts listed for your child in addition to parents/guardians.
Name: Relation to Child: Cellphone: Work Telephone: Name: Relation to Child: Cellphone: Work Telephone: Name: Relation to Child: Cellphone: Work Telephone: ADDITIONAL EMERGENCY CONTACTS / AUTHORIZED PICK-UPS Please list below additional individuals who are authorized to pick up your child from the program. (Optional)
Name: Relation to Child: Cellphone: Work Telephone: Name: Relation to Child: Cellphone: Work Telephone: Please note any special instructions regarding individuals listed: *Parents and legal guardians listed on enrollment forms are automatically authorized to pick up your child unless the program is given a copy of a current court ordered custody agreement or restraining order. All individuals authorized to pick up your child from the program must be at least 16 years of age. A license or other positive proof of identification must be shown at pick up. If you wish to change, add, or delete any of these authorizations, you must do so in writing. INITIAL Should a person arrive to pick up my child who appears to be under the influence of drugs or alcohol, staff may have no recourse but to contact the police. This is for the child’s safety.
I HAVE READ, UNDERSTAND, AND AGREE TO THE CONDITIONS AS STATED ABOVE Parent/Guardian Printed Name: Parent/Guardian Signature: Date:
2019 YMCA OF GREENWICH
MEDICAL INFORMATION
SUMMER DAY CAMP & AUTHORIZATION
Child’s Name: Date of Birth: Medical Insurance Company: Policy #: Other Coverage (Including Dental): Child’s Physician: Phone #: Address: Child’s Dentist: Phone #: Address: MEDICAL HISTORY
All children having disabilities or special health care needs such as allergies, special dietary needs, dental problems, hearing or visual impairments, chronic illness, developmental variations or history of contagious disease are required to have an Individual Plan of Care developed by the child’s parents/guardians and center Director. Additional related persons (i.e. child’s physician, Health Consultant, Education Consultant, etc.) may be required to assist with developing the plan based upon the child’s condition and needs. Please contact the center Director in order to develop the child’s Individual Plan of Care. Please write “NONE” if there are none. Allergies
Reactions
Treatments
Special Disabilities/Needs/Chronic Health Conditions: Does your child have an IEP? Yes No If yes, the YMCA requests information to be shared to enable us to provide the best camp experience for your child. Parent/Guardian Signature: Current Medications: Emergency Medical/Dietary Information/Religious Restrictions: Behavioral Issues: Other Health Concerns:
MEDICAL TREATMENT CONSENT
I hereby authorize the staff of the YMCA of Greenwich to give First Aid and CPR to my child as needed. I understand that the staff is trained in the basics of First Aid and CPR. In the event of an emergency, I hereby authorize the program staff to have my child transported to the nearest medical facility or to _________________ and secure necessary medical treatment including, but not limited to: hospitalization, injections, anesthesia and/or surgery. In the event that I cannot be reached, I hereby give permission to the physicians attending to my child to secure and administer treatment as necessary. I understand that the staff will make every effort to notify me of the emergency immediately. Any expenses incurred will be the responsibility of the parent/guardian. INITIAL I certify that a licensed physician has examined my child in the last 12 months and I have provided the YMCA of Greenwich Summer Camp with proper documentation, clearly stating date of physical & immunization records. INITIAL I acknowledge it is my responsibility to keep my child’s records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child’s physician, child’s health status, immunization records, etc.
I HAVE READ, UNDERSTAND, AND AGREE TO THE CONDITIONS AS STATED ABOVE Parent/Guardian Printed Name: Parent/Guardian Signature: Date:
2019 YMCA OF GREENWICH
SUMMER DAY CAMP
AGREEMENT & CONSENT FORM
PROMOTIONAL RELEASE
I hereby grant consent and authorize the use of photographs, slides, videotape, and film of my child participating in YMCA of Greenwich activities for commercial and art purposes in any medium of advertising, communication, publication, or publicity that will promote YMCA of Greenwich programs and services, and/or recognition of participants. I understand that the YMCA is a non-profit organization. Parent/Guardian Printed Name: Parent/Guardian Signature:
SUPPORT STAFF CONSENT
The YMCA of Greenwich Programs have support staff that consists of educational resource advisors, consultants, family support specialists, and social services staff. In addition, student interns and/or volunteers may work within the program. I give permission for my child to interact with these support staff. Parent/Guardian Printed Name: Parent/Guardian Signature:
FACILITY USES
I grant permission for my child to use all of the play equipment and participate in all of the activities of the program with the exception of _________________________________. Parent/Guardian Printed Name: Parent/Guardian Signature:
ACTIVITIES OFF SITE
I hereby grant consent for my child to leave the program premises under the supervision of a staff member in an authorized vehicle to the Main YMCA facility. I understand that any other activity destination or field trip will require my written permission. Parent/Guardian Printed Name: Parent/Guardian Signature:
SWIMMING CONSENT
I hereby grant consent for my child to participate in swimming in life guarded places only. My child’s ability to swim is: Non-Swimmer Beginner Intermediate
Advanced
Parent/Guardian Printed Name: Parent/Guardian Signature:
PARENT AGREEMENT INITIAL I understand that YMCA staff and volunteers are not allowed to baby-sit or transport children in personal vehicles at any time outside of the YMCA program. INITIAL I understand that I am not to leave my child at the YMCA or program site unless a YMCA staff or volunteer is present to receive and supervise my child. INITIAL I understand that the YMCA is mandated, by state law, to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation. INITIAL
The YMCA staff has specifically discussed the behavior management techniques that are used in the program.
Parent/Guardian Printed Name: Parent/Guardian Signature: Date:
